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Certificate of Insurance Request

General Information
Name of Insured:
Name or Company of Certificate Holder:
Job Reference No.:
Address of Holder:
Street Address Address Line 2 City State ZIP Code
Holder Phone:
Holder Fax:
Your Name:*
Contact Email Address:*
Handling Method:
- Fax
- Email
Required Coverages
Please provide copy of insurance requirements of contract:
- Auto
- Umbrella
- General Liability
- Equipment
- Workers' Compensation
- Builders Risk
General Liability Description:
Need Endorsements for Waiver of Subrogation:
- Yes
- No
Need Endorsements for Primary Wording:
- Yes
- No
Loss Payee:
- Yes
- No
Mortgagee:
- Yes
- No
Additional Insured:
- Yes
- No
Comments or Other Instructions
Attach File
Please attach written request(s) and/or contracts received, if any.
Max. file size: 59 MB.
Phone
This field is for validation purposes and should be left unchanged.

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Willis Insurance Agency

310 West Main Street
Bellevue, Ohio 44811

Call/Text: (419) 483-4833

Fax: (419) 483-3104

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Sat: 9:00am-12:00pm
Sun: Closed

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Willis Insurance Agency Provides Auto/Car Insurance, Home Insurance, Business/Commercial Insurance, and Life Insurance to All of Ohio, Including Bellevue, Clyde, and Sandusky.

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